非手术干预引导骨再生术后屏障膜早期暴露的转归及其对骨愈合的影响

The non-surgical interventions to early exposure of barrier membranes after guided bone regeneration: clinical observation of different outcomes and its impact on bone healing

目的研究种植体植入同期引导骨再生(GBR)患者术后伤口裂开、屏障膜过早暴露于口腔环境后,非手术干预处理后的不同转归及其对种植区软硬组织的影响。方法 128例牙槽嵴骨量不足需行牙种植体植入同期GBR的患者纳入本临床研究。术后发现伤口早期局限性裂开后立即行1～3周的非手术干预治疗。分别记录术后2周内伤口裂开、3周非手术干预期间和Ⅱ期手术时软组织愈合的临床数据。分别于术后当天和Ⅱ期手术前拍摄术区的标准化根尖X线片,以评价膜暴露的不同转归对种植体骨结合、边缘骨吸收(MBL)的影响。结果 128例患者术后2周内伤口裂开的发生率高达52.34%。其中3例患者由于感染导致种植体骨结合失败,未能完成后续的实验。其余的125例患者根据伤口愈合情况将患者分为3组:(1)A组,伤口裂开伴脱细胞真皮基质(ADM)膜早期暴露,共53例;(2)B组,ADM膜早期穿孔伴覆盖螺丝暴露,共12例;(3)C组,伤口无裂开正常愈合,共60例。通过非手术治疗,A组所有膜早期暴露的患者暴露的膜均逐渐被牙龈组织重新覆盖。Ⅱ期手术时,种植体近远中MBL情况,A组有12例,吸收量分别为(0.48±0.19)mm、(0.52±0.24)mm,B组有11例,吸收量分别为(1.00±0.39)mm、(0.80±0.40)mm,C组仅2例发生MBL。t检验结果显示,A和B组内近中和远中的MBL差异均无统计学意义(P>0.05);A组和B组近远中MBL的组间差异有统计学意义(P<0.05),A组和C组近远中MBL的组间差异无统计学意义。结论及时非手术干预通过维持创面清洁、预防感染,推迟早期暴露膜在体内的降解,促进上皮愈合,降低对骨愈合的不利影响,是挽救GBR术后伤口裂开获得延期愈合的有效治疗方法。

Objectives To observe the different outcomes of wound dehiscence which was treated by non-surgical methods after implant placement simultaneously guided bone regeneration （GBR） surgery using aeellular dermal matrix （ADM） as barrier membrane and its impact on the soft and hard tissues in the implant sites. Methods 128 patients with inadequate vestibulolingual bone volume at alveolar ridge to accommodate the dental implant were selected to perform implant placement with simultaneously in this clinical study. Non-surgical interventions on the treated area were carried out immediately for 1 to 3 weeks with early wound dehiscence over the ADM. Clinical data on wound healing at 2 weeks post-surgery, during the 3 weeks of non-surgical treatment and at the time of second-stage surgery was recorded, respectively. Standardized periapical radiographs of the operated site on the day after surgery and before the second stage surgery were taken, to evaluate the effects of different outcomes on osseointegrationand crestal bone loss, respectively. Results The total rate for wound dehiscence in 128 patients was as high as at 52.34% within 2 weeks post-surgery. In 3 patients, 3 implants were failed to achieve osseointegration because of infection, and excluded from the subsequent study. The remaining 125 patients were divided into 3 groups according to the wound healing, Group A （53 cases）： wound dehiscence with early ADM exposure. Group B （12 cases）： ADM perforation accompanied by early cover screw exposure. Group C （60 cases）： normal wound healing without dehiscence. With the aid of the non-surgical therapy, the exposed membranes were gradually covered with gingival tissue in all the patients with premature membrane exposure. Within group A, there was marginal bone loss （MBL） in 12 patients, the mean mesial （M） and distal （D） marginal bone were （0.48±0.19） mm and （0.52 ± 0.19） mm; MBL occurred in 11 patients, the mean M and D MBL were （1.00±0.39） mm and （0.80±0.40） mm, respectively; MBL occurred in only 2 patients of group C. The results of t test showed： No significant differences of the mesial and distal MBL were found within A and B groups （P〉 0.05）; while there were remarkable differences between group A and group B for mesial and distal MBL （P〈 0.05）. However, differences of mesial and distal MBL between Group A and Group C were not statistically significant （P〉 0.05）. Conclusions The timely non-surgical intervention to early barrier membrane exposure after GBR surgery could maintain the surface of the wound clean, prevent infection, delay the degradation of the membrane, promote epithelialization, and reduce the adverse effects on bone healing; so it was an effective strategy to obtain delayed soft tissue healing.